TCC Nursing ProgramNUR 2564 – Advanced Medical Surgical

Key ProblemRisk for Infection

Supporting DataWBC count 15.33: Central line placed: currently septic: surgery yesterday to remove squamous cell carcinoma on chest wall: Currently Intubated: has indwelling Foley catheter

Client Goal: Client will not acquire any further infections; WBC count will begin to normalize as patient responds to antibiotic therapy

Key ProblemRisk for Aspiration

Supporting Data: Patient is currently intubated with endotracheal tube and is receiving supplemental nutrition via nasogastric tube

Client Goal: Swallow and digest nasogastric feeding without aspiration

Key ProblemFluid Volume Excess

Supporting Data: CXR indicating cardiomegaly with evidence of fluid volume overload, right mid lung edema; Lung sounds diminished bilaterally at the bases, edema present and patient looks generally puffy. BNP of 2547.5; Input exceeded output with a negative 1583ml

Client Goal: Remain free of jugular vein distention, positive hepatojugular reflex, and gallop heart rhythm

Key ProblemDecreased cardiac output

Supporting Data: Patient converted from a normal sinus rhythm to atrial fibrillation with RVR spontaneously in the night.

Client Goal: Remain free of side effects from the medications used to achieve adequate cardiac output

Key Problem:Impaired Gas ExchangeSupporting Data: Abnormal blood gasses; pCO2-31mm/Hg; pH 7.28; pO2 125 mm Hg; CO2 21; Lower extremities were blue-purple in color indicating poor perfusion; CXR indicating fluid volume overload and small bilateral pleural effusions.

Client Goal: Demonstrate improved ventilation and adequate oxygenation as evidenced by blood gas levels within normal parameters for that client

Key ProblemRisk for Electrolyte Imbalance

Supporting Data: evidence of fluid volume overload and the patient also has kidney disease; BUN 54; Creatinine 2.80; CA 7.9; Na 134; K 4.5; Phos 4.2; mag 2.4; Input exceeded output with a negative 1583mls

Client Goal: Patient will attain normal serum potassium, sodium, calcium, and phosphorus

What is client’s significant history and/or co-morbidities?HTN, CKD, bilat lung transplant 2004, hx of rejection & chronic host vs graft rejection. Hx of A-fib, CAD, stent placed in 2003, single vessel disease, squamous cell carcinoma on chest wall.Has the client had any significant procedures/surgies during this admission?Pt. was intubated on arrivalDoes the client have family? wife has stayed at the bedside.Other significant data: Patient converted from NSR in the 70-80bpm range to atrial fibrillation with RVR. Pt. was started on an IV drip of Heparin @ 30mL/hr. The pt. is immunosuppressed, currently septic, has fluid volume overload. My interpretation of the ABG’s indicating partially compensated metabolic acidosis.

Why was the client admitted?Pt. Was life-flighted from outlying hospital where he was evaluated pH 7.2 & pCO2 of 60, CXR showing CHF, cardiomegaly, volume overload. Outlying hospital was not equipped to care for the pt.

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